coding, diagnosing, billing, reimbursement & documentation strategies for psychological services
TRANSCRIPT
Coding, Diagnosing, Coding, Diagnosing, Billing, Billing,
Reimbursement & Reimbursement & Documentation Documentation Strategies for Strategies for Psychological Psychological
ServicesServices
North Carolina Psychological North Carolina Psychological AssociationAssociation
April 26, 2002; Charlotte, NCApril 26, 2002; Charlotte, NC
Antonio E. Puente, Ph.D.
Department of Psychology
University of North Carolina at Wilmington
Wilmington, NC 28403
AcknowledgmentsAcknowledgments
NCPA Board of Directors, Practice Division, & Staff NAN Board of Directors, Policy and Planning
Committee, & Professional Affairs & Information Office
Division 40 Board of Directors & Practice Committee Practice Directorate of the American Psychological
Association American Medical Association’s CPT Staff CMS Medical Policy Staff
BackgroundBackgroundNorth Carolina Psychological AssociationAmerican Medical Association’s Current
Procedural Terminology Committee (IV/V)Health Care Finance Administration’
Working Group for a Model Mental Health policy
Center for Medicare/Medicaid Services’ Medicare Coverage Advisory Committee
Development of NAN’s new PAIOConsultant with the State Medicaid Office;
Blue Cross/Blue ShieldAPA; Council of Rep, Division 40, P & P
Purpose of PresentationPurpose of Presentation
Increase ReimbursementDecrease Fraud & AbuseProvide Professional GuidelinesIncrease Range, Type & Quality of ServicesIncrease Professional Stature in Health Care
Outline of PresentationOutline of Presentation
MedicareCurrent Procedural Terminology: Basic Current Procedural Terminology: RelatedRelative Value UnitsCurrent Problems & Possible SolutionsFuture Directions & ProblemsCases & Questions
Outline: HighlightsOutline: Highlights
New CodesExpanding ParadigmsFraud, Abuse; Coding & DocumentationThe Problem with Testing
Medicare: OverviewMedicare: Overview
Why MedicareMedicare ProgramLocal Medical Review
Medicare: WhyMedicare: Why
The Standard – Coding– Value– Documentation
Approximately 50% for InstitutionsApproximately 33% for Outpatient OfficesBecoming the Standard for Workers Comp.Increasing Percentage for Forensic Work
Medicare: OverviewMedicare: Overview
New Name: HCFA now CMS– Centers for Medicare and Medicaid Services
New Charge: SimplifyNew Organization: Beneficiary, Medicare,
MedicaidBenefits
– Part A (Hospital)– Part B (Supplementary)– Part C (Medicare+ Choice)
Medicare: Local ReviewMedicare: Local Review
Local Medical Review PolicyCarrier Medical DirectorPolicy Panels
Current Procedural Current Procedural Terminology: OverviewTerminology: Overview
Background Codes & Coding Existing Codes New Codes (effective 01.01.02; revised 03.15.02) Model System X Type of Problem Medical Necessity Documenting Time
CPT: HighlightsCPT: Highlights
New CodesMedical NecessityDocumentation
CPT: BackgroundCPT: Background
American Medical Association– Developed by Surgeons (& Physicians) in 1966 for
Billing Purposes– 7,500 Discrete Codes
HCFA/CMS– AMA Under License with CMS– CMS Now Provides Active Input into CPT
Congress– Trent Lott (2001)
CPT: Background/DirectionCPT: Background/Direction
Current System = CPT 5Categories
– I= Standard Coding for Professional Services– II = Performance Measurement– III = Emerging Technology
CPT: Applicable CodesCPT: Applicable Codes
Total Possible Codes = 7,500Possible Codes for Psychology = Approximately
40 to 60Sections = Five Separate Sections
– Psychiatry– Biofeedback– Central Nervous Assessment– Physical Medicine & Rehabilitation– Health & Behavior Assessment & Management
CPT: Development of a CodeCPT: Development of a Code
Initial– HCPAC
Primary– CPT Work Group– CPT Panel
Time Frame– 3-5 years
CPT: PsychiatryCPT: Psychiatry
Sections– Interview vs. Intervention– Office vs. Inpatient– Regular vs. Evaluation & Management– Other
Types of Interventions– Insight, Behavior Modifying, and/or Supportive
vs. Interactive
CPT: Psychiatry (cont.)CPT: Psychiatry (cont.)
Time Value– 30, 60, or 90
Interview– 90801
Intervention– 90804 - 90857
CPT: BiofeedbackCPT: Biofeedback
Psychophysiological Training– 90901
Biofeedback– 90875
CPT: CNS AssessmentCPT: CNS Assessment
Interview– 96115
Testing– Psychological = 96100; 96110/11– Neuropsychological = 96117– Other = 96105, 96110/111
CPT: 96117 in DetailCPT: 96117 in Detail
Number of Encounters in 2000 = 293,000Number of Medical Specialties Using
96117 = over 40Psychiatry & Neurology = Approximately
3% eachClinics or Other Groups = 3%Unknown Data = Use of Technicians
CPT: Physical Medicine & CPT: Physical Medicine & RehabilitationRehabilitation
97770 now 97532Note: 15 minute increments
CPT: Health & Behavior CPT: Health & Behavior Assessment & Mngmt.Assessment & Mngmt.
Purpose: Medical DiagnosisTime: 15 Minute IncrementsAssessmentIntervention
Rationale: GeneralRationale: General
Acute or chronic (health) illness may not meet the criteria for a psychiatric diagnosis
Avoids inappropriate labeling of a patient as having a mental health disorder
Increases the accuracy of correct coding of professional services
May expand the type of assessments and interventions afforded to individuals with health problems
Rationale: Specific ExamplesRationale: Specific Examples
Patient Adherence to Medical TreatmentSymptom Management & ExpressionHealth-promoting BehaviorsHealth-related Risk-taking BehaviorsOverall Adjustment to Medical Illness
Overview of CodesOverview of Codes
New SubsectionSix New Codes
– Assessment– Intervention
Established Medical Illness or DiagnosisFocus on Biopsychosocial Factors
Assessment ExplanationAssessment Explanation
Identification of psychological, behavioral, emotional, cognitive, and social factors
In the prevention, treatment, and/or management of physical health problems
Focus on biopsychosocial factors (not mental health)
Assessment (continued)Assessment (continued)
May include (examples);– health-focused clinical interview– behavioral observations– psychophysiological monitoring– health-oriented questionnaires– and, assessment/interpretation of the
aforementioned
Intervention ExplanationIntervention Explanation
Modification of psychological, behavioral, emotional, cognitive, and/or social factors
Affecting physiological functioning, disease status, health, and/or well being
Focus = improvement of health with cognitive, behavioral, social, and/or psychophysiological procedures
Intervention (continued)Intervention (continued)
May include the following procedures (examples);– Cognitive– Behavioral– Social– Psychophysiological
Diagnosis MatchDiagnosis Match
Associated with acute or chronic illnessPrevention of a physical illness or disabilityNot meeting criteria for a psychiatric
diagnosis or representing a preventative medicine service
Related Psychiatric CodesRelated Psychiatric Codes
If psychiatric services are required (90801-90899) along with these, report predominant service
Do not report psychiatric and these codes on the same day
Related Evaluation & Related Evaluation & Management CodesManagement Codes
Do not report Evaluation & Management codes the same day
Code X Personnel (examples)Code X Personnel (examples)
Physicians (pediatricians, family physicians, internists, & psychiatrists)
PsychologistsAdvanced Practice NursesClinical Social WorkersOther health care professionals within their scope
of practice who have specialty or subspecialty training in health and behavior assessments and interventions
Health & Behavior Health & Behavior Assessment CodesAssessment Codes
96150– Health and behavior assessment (e.g., health-focused
clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires)
– each 15 minutes– face-to-face with the patient– initial assessment
96151– re-assessment
Health & Behavior Intervention Health & Behavior Intervention CodesCodes
96152– Health and behavior intervention– each 15 minutes– face-to-face– individual
96153– group (2 or more patients)
96154– family (with the patient present)
96155– family (without the patient present)
Relative Values for Health & Relative Values for Health & Behavior A/I CodesBehavior A/I Codes
96150 = .5096151 = .4896152 = . 4696153 = .1096154 = .4596155 = .44
Sample of Commonly Asked Sample of Commonly Asked QuestionsQuestions
When Are These Codes to be Used for Psychotherapy Codes?– Depends on the disorder– DSM = psychotherapy– ICD = health and behavior
Samples Questions Samples Questions (continued)(continued)
Do These Codes Include Neuropsychological Testing?– No– Formal testing should be coded between 96100
and 96117, depending on the situation
Sample Questions (continued)Sample Questions (continued)
Who Can Perform These Services?– Physicians can perform these services– Application of these codes will vary according
to licensure/credentialing requirements of the state, area, providence and/or institution
– Payment may also vary
96150 Clinical Example96150 Clinical Example A 5-year-old boy undergoing treatment for acute
lymphoblastic leukemia is referred for assessment of pain, severe behavioral distress and combativeness associated with repeated lumbar punctures and intrathecal chemotherapy administration. Previously unsuccessful approaches had included pharmacologic treatment of anxiety (ativan), conscious sedation using Versed and finally, chlorohydrate, which only exacerbated the child’s distress as a result of partial sedation. General anesthesia was ruled out because the child’s asthma increased anesthesia respiratory risk to unacceptable levels.
96150 Description of 96150 Description of ProcedureProcedure
The patient was assessed using standardized tests and questionnaires (e.g., the Information-seeking scale, Pediatric Pain Questionnaire, Coping Strategies Inventory) which, in view of the child’s age, were administered in a structured format. The medical staff and child’s parents were also interviewed. On the day of a scheduled medical procedure, the child completed a self-report distress questionnaire.Behavioral observations were also made during the procedure using the CAMPIS-R, a structured observation scale that quantifies child, parent, and medical staff behavior.
An assessment of the patient’s condition was performed through the administration of various health and behavior instruments.
96151 Clinical Example96151 Clinical Example A 35-year-old female, diagnosed with chronic asthma,
hypertension and panic attacks was originally seen ten months ago for assessment and follow-up treatment. Original assessment included extensive interview regarding patient’s emotional, social, and medical history, including her ability to manage problems related to the chronic asthma, hospitalizations, and treatments. Test results from original assessment provided information for treatment planning which included health and behavior interventions using a combination of behavioral cognitive therapy, relaxation response training and visualization. After four months of treatment interventions, the patient’s hypertension and anxiety were significantly reduced and thus the patient was discharged. Now six months following discharge, the patient has injured her knee and has undergone arthroscopic surgery with follow-up therapy
96151 Description of 96151 Description of ProcedureProcedure
Patient was seen to reassess and evaluate psychophysiological responses to these new health stressors. A review of the records from the initial assessment, including testing and treatment intervention, as well as current medical records was made. Patient’s affective and physiological status, compliance disposition, and perceptions of efficacy of relaxation and visualization practices utilized during previous treatment intervention are examined. Administration of anxiety inventory/questionnaire (e.g., Burns Anxiety Inventory) is used to quantify patient’s current level of response to present health stressors and compared to original assessment levels. Need for further treatment is evaluated.
A reassessment of the patients condition was performed through the use of interview and behavioral health instruments.
96152 Clinical Example96152 Clinical Example
A 55-year-old executive has a history of cardiac arrest, high blood pressure and cholesterol, and a family history of cardiac problems. He is 30 lbs. overweight, travels extensively for work, and reports to be a moderate social drinker. He currently smokes one-half pack of cigarettes a day, although he had periodically attempted to quit smoking for up to five weeks at a time. The patient is considered by his physician to be a “Type A” personality and at high risk for cardiac complications. He experiences angina pains one or two times per month. The patient is seen by a behavior medicine specialist. Results from the health and behavior assessment are used to develop a treatment plan, taking into account the patient’s coping skills and lifestyle.
96152 Description of 96152 Description of ProcedureProcedure
Weekly intervention sessions focus on psychoeducational factors impacting his awareness and knowledge about his disease process, and the use of relaxation and guided imagery techniques that directly impact his blood pressure and heart rate. Cognitive and behavioral approaches for cessation of smoking and initiation of an appropriate physician-prescribed diet and exercise regimen are also employed.
96153 Clinical Example96153 Clinical Example A 45-year-old female is referred for smoking
cessation secondary to chronic bronchitis, with a strong family history of emphysema. She smokes two packs per day. The health and behavior assessment reveals that the patient uses smoking as a primary way of coping with stress. Social Influences contributing to her continued smoking include several friends and family members who also smoke. The patient has made multiple previous attempts to quit “on her own”. When treatment options are reviewed, she is receptive to the recommendation of an eight-session group cessation program.
96153 Description of 96153 Description of ProcedureProcedure
The program components include educational information (e.g., health risks, nicotine addiction), cognitive-behavioral treatment (e.g., self-monitoring, relaxation training, and behavioral substitution), and social support (e.g., group discussion, social skills training). Participants taper intake over four weeks to a quit date and then attend three more sessions for relapse prevention. Each group sessions lasts 1.5 hrs.
96154 Clinical Example96154 Clinical Example
Tara is a 9-year-old girl, diagnosed with insulin dependent diabetes two years ago. Her mother reports great difficulty with morning and evening insulin injections and blood glucose testing. Tara whines and cries, delaying the procedures for 30 minutes or more. She refused to give her own injections or conduct her own blood glucose tests, claiming they “hurt”. Her mother spends many minutes pleading for her cooperation. Tara’s father refuses to participate, saying he is “afraid” of her needles. Both parents have not been able to go to a movie or dinner alone, because they know of no one who can care for Tara. Tara’s ten year old sister claims she never has any time with her mother, since her mother is always occupied with Tara’s illness. Tara and her sister have a very poor relationship and are always quarreling. Tara’s parents frequently argue; her mother complains that she gets no help from her husband. Tara’s father complains that his wife has no time for anyone except Tara.
96154 Description of 96154 Description of ProcedureProcedure
A family-based approach is used to address the multiple components of Tara’s problem behaviors. Relaxation and exposure techniques are used to address Tara’s father’s fear of injections, which he has inadvertently has been modeling for Tara. Tara is taught relaxation and distraction techniques to reduce the tension she experiences with finger sticks and injections. Both parents are taught to shape Tara’s behavior, praising and rewarding successful diabetes management behaviors, and ignoring delay tactics. Her parents are also taught judicious use of time-out and response cost procedures. Family roles and responsibilities are clarified. Clear communication, conflict-resolution, and problem-solving skills are taught. Family members practice applying these skills to a variety of problems so that they will know how to successfully address new problems that may arise in the future.
96155 Clinical Example96155 Clinical Example
Greg is a 42-year-old male diagnosed with cancer of the pancreas. He is currently undergoing both aggressive chemotherapy and radiation treatments. However, his prognosis is guarded. At present, he is not in the endstage disease process and therefore does not qualify for Hospice care. The patient is seen initially to address issues of pain management via imagery, breathing exercises, and other therapeutic interventions to assess quality of life issues, treatment options, and death and dying issues.
96155 Description of 96155 Description of ProcedureProcedure
Due to the medical protocol and the patient’s inability to travel to additional sessions between hospitalizations, a plan is developed for extending treatment at home via the patient’s wife, who is his primary home caregiver. The patient’s wife is seen by the healthcare provider to train the wife in how to assist the patient in objectively monitoring his pain and in applying exercises learned via his treatment sessions to manage pain. Issues of the patient’s quality of life, as well as death and dying concerns, are also addressed with assistance given to the wife as to how to make appropriate home interventions between sessions. Effective communication techniques with her husband’s physician and other members of his treatment team regarding his treatment protocols are facilitated.
CPT: ModifiersCPT: Modifiers
Acceptability– Medicare = about 100%– Others = approximating 90%
Modifiers– 22 = unusual or more extensive service– 51 = multiple procedures– 52 = reduced service– 53 = discontinued service
CPT: Model SystemCPT: Model System
PsychiatricNeurologicalNon-Neurological Medical
CPT: Psychiatric ModelCPT: Psychiatric Model(Children & Adult)(Children & Adult)
Interview– 90801
Testing– 96100, or– 96110/11
Intervention– e.g., 90806– The challenge of New Mexico
CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)
Interview– 96115
Testing– 96117
Intervention– 97532
CPT: Non-Neurological CPT: Non-Neurological Medical ModelMedical Model
(Children & Adult)(Children & Adult)Interview & Assessment
– 96150 (initial)– 96151 (re-evaluation)
Intervention– 96152 (individual)– 96153 (group)– 96154 (family with patient)– 96155 (family without patient)
CPT: New ParadigmsCPT: New Paradigms
Initial PsychiatricNext NeurologicalNow MedicalMedical as Evaluation & Management
CPT: Evaluation & CPT: Evaluation & ManagementManagement
Role of Evaluation & Management Codes– Procedures– Case Management
Limitations Imposed by AMA’s House of Delegates
Health & Behavior Codes as an Alternative to E & M Codes
CPT: DiagnosingCPT: Diagnosing
Psychiatric– DSM
The problem with DSM and neuropsych testing of developmentally-related neurological problems
Neurological & Non-Neurological Medical– ICD
CPT: Medical NecessityCPT: Medical Necessity
Scientific & Clinical NecessityLocal Medical Review or Carrier Definition
of NecessityNecessity = CPT x DXNecessity Dictates Type and Level of ServiceNecessity Can Only be Proven with
Documentation
CPT: DocumentingCPT: Documenting
PurposePayer RequirementsGeneral PrinciplesHistoryExaminationDecision Making
Documentation: PurposeDocumentation: Purpose
Medical NecessityEvaluate and Plan for TreatmentCommunication and Continuity of CareClaims Review and PaymentResearch and Education
Documentation: Payer Documentation: Payer RequirementsRequirements
Site of ServiceMedical Necessity for Service ProvidedAppropriate Reporting of Activity
Documentation: General Documentation: General PrinciplesPrinciples
Rationale for ServiceComplete and LegibleReason/Rationale for ServiceAssessment, Progress, Impression, or
DiagnosisPlan for CareDate and Identity of ObserveTimelyConfidential
Documentation: Basic Documentation: Basic Information Across All CodesInformation Across All Codes
Date Time, if applicable Identify of Observer Reason for Service Status Procedure Results/Finding Impression/Diagnoses Disposition Stand Alone
Documentation: Chief Documentation: Chief ComplaintComplaint
Concise Statement Describing the Symptom, Problem, Condition, & Diagnosis
Foundation for Medical NecessityMust be Complete & Exhaustive
Documentation: Present Documentation: Present IllnessIllness
Symptoms– Location, Quality, Severity, Duration, timing,
Context, Modifying Factors Associated Signs
Follow-up– Changes in Condition– Compliance
Documentation: HistoryDocumentation: History
PastFamily SocialMedical/Psych ?
Documentation:Documentation:Mental StatusMental Status
Language Thought Processes Insight Judgment Reliability Reasoning Perceptions
Suicidality Violence Mood & Affect Orientation Memory Attention Intelligence
Documentation:Documentation:Neurobehavioral Status ExamNeurobehavioral Status ExamAttentionMemoryVisuo-spatialLanguage Planning
Documentation: TestingDocumentation: Testing
Names of TestsInterpretation of TestsDispositionTime/Dates
Documentation: Documentation: InterventionIntervention
Reason for ServiceStatusInterventionResultsImpressionDispositionTime
Documentation:Documentation:SuggestionsSuggestions
Avoid Handwritten NotesDo Not Use Red InkDocument On and After Every Encounter,
Every Procedure, Every PatientReview Changes Whenever ApplicableAvoid Standard Phrases
Documentation: Ethical IssuesDocumentation: Ethical Issues
How Much and To Whom Should Information be Divulged
Medical Necessity vs. Confidentiality
TimeTime
Defining– Professional (not patient) Time Including:
pre, intra & post-clinical service activities
Interview & Assessment Codes– Generally use hourly increments– For new codes, use 15 minute increments
Intervention Codes– Use 15, 30, or 60 minute increments
Time: DefinitionTime: Definition
AMA Definition of Time
Physicians also spend time during work, before, or after the face-to-face time with the patient, performing such tasks as reviewing records & tests, arranging for services & communicating further with other professionals & the patient through written reports & telephone contact.
Time (continued)Time (continued)
Communicating further with othersFollow-up with patient, family, and/or
othersArranging for ancillary and/or other
services
Time: TestingTime: Testing
Quantifying Time– Round up or down to nearest increment– Testing = 15 or 60 (probably soon 30)
Time Does Not Include– Patient completing tests, forms, etc.– Waiting time by patient– Typing of reports– Non-Professional (e.g., clerical) time– Literature searches, new techniques, etc.
Time (continued)Time (continued)
Preparing to See Patient Reviewing of Records Interviewing Patient, Family, and Others When Doing Assessments:
– Selection of tests– Scoring of tests– Reviewing results– Interpretation of results– Preparation and report writing
Time: Example of 96117Time: Example of 96117
Pre-Service– Review of medical records– Planning of testing
Intra-Service– Administration
Post-Service– Scoring, interpretation, integration with other
records, written report, follow-up...
Reimbursement HistoryReimbursement History
Cost Plus Prospective Payment System (PPS)Diagnostic Related Groups (DRGs)Customary, prevailing & Reasonable (CPR)Resource Based Relative Value System
(RBRVS)Prospective Payment System
Relative Value Units: Relative Value Units: OverviewOverview
ComponentsUnitsValuesCurrent Problems
RVU: ComponentsRVU: Components
Physician Work Resource ValuePractice Expense Resource ValueMalpracticeGeographicConversion Factor (approx. $34)
RVU: ValuesRVU: Values
Psychotherapy:– Prior Value =1.86– New Value = 2.0+ (01.01.02)
Psych/NP Testing: – Work value= 0– Hsiao study recommendation = 2.2– New Value = undetermined
Health & Behavior– .25 (per 15 minutes increments)
RVU: AcceptanceRVU: Acceptance
MedicareBlue Cross/Blue Shield 87%Managed Care 69%Medicaid 55%Other 44%New Trends: Compensation Formulas
Current Problems Current Problems Definition of Physician Incident to Supervision Face-to-Face Time RVUs Work Values Qualification of Technicians Practice Expense Payment Prospective Payment System Focus for Fraud & Abuse
Current Problems: HighlightsCurrent Problems: Highlights
Work ValueProvision & Coding of Technical Services
(e.g., who is qualified to provide them)Mental vs. Physical Health
Problem: Defining PhysicianProblem: Defining Physician
Definition of a Physician– Social Security Practice Act of 1980– Definition of a Physician– Need for Congressional Act– Likelihood of Congressional Act– The Value of Technical Services of a Psychologist is
$.83/hour (second highest after physicist)– Consequence of the preceding; grouping with non-
doctoral level allied health providers
Problem: Incident toProblem: Incident to
Definition of Physician Extender– How– Limitations
Definition of In vs. Outpatient– Geographic Vs Financial
Why No Incident to (DRG) Solution Available for Some Training Programs Probably no Future to Incident to
Problem: More Incident toProblem: More Incident to
When is Incident to Acceptable:– Testing (Cognitive Rehabilitation; Biofeedback)– Psychotherapy
Definition– Commonly furnished service– Integral, though incidental to psychologist– Performed under the supervision– Either furnished without charge or as part of the
psychologist’s charge
Problem: Incident to & Site of Problem: Incident to & Site of ServiceService
Outpatient vs. Inpatient– Geographical Location– Corporate Relationship– Billing Service– Chart Information & Location
Problem:SupervisionProblem:Supervision
Supervision– 1.General = overall direction– 2.Direct = present in office suite– 3.Personal = in actual room– 4.Psychological = when supervised by a
psychologist
Problem: Face-to-FaceProblem: Face-to-Face
ImplicationsTechnical versus Professional ServicesSurgery is the Foundation for CPT (and
most work is face-to-face)Hard to Document & Trace Non-Face-to-
Face Work
Problem: TimeProblem: Time
Time Based Professional ActivityCurrent =15, 30, 60, & 90 Expected = 15 & 30
Problem: RVUsProblem: RVUs
Bad News– 2000 = 5.5% increase– 2001 = 4.5% increase– 2002 = 5.4% decrease– 2003 = 5.7% decrease ($34.14)
Really Bad News– Projected cuts of about 7% more– Bush Administration not supportive of changing the
conversion formula
Problem: Work ValueProblem: Work Value
Physician Activities (e.g., Psychotherapy) Result in Work Values
Psychological Based Activities (I.e., Testing) Have no Work Values
RVUs are Heavily Based on Practice Expenses (which are being reduced)
Net Result = Maybe Up to a Half Lower
Problem: Qualification of Problem: Qualification of TechnicianTechnician
What is the Minimum Level of Training Required for a Technician?– Bachelor’s vs. Masters– Intern vs. Postdoctoral
Will a Registry be Available?
Practice Expense: The Practice Expense: The Problem with TestingProblem with Testing
Five Year ReviewsPrior MethodologyCurrent MethodologyCurrent Value = approximately 1.5 of 1.75
is practiceExpected Value = closer to 50% of total
value
Problem: PaymentProblem: Payment
Refilling– 51% require refilling
Errors– 54% = plan administrator– 17% = provider– 29% = member
State Legislation– www.insure.com/health/lawtool.cfm
Problem: PaymentProblem: Payment
Use of HMOs & Third Party– Shift in Practice Patterns by Psychiatry (14% increase)– Exclusion of MSW, etc.– Worst Hit Are Psychologists (2% decrease)
Compensation– Gross Charges– Adjusted Charges– RVUs– Receivables
Problem: PPSProblem: PPS
Application of PPS (inpatient rehab)Traditional ReimbursementCurrent UnbundlingPotential Situation
Problem: Expenditures & Problem: Expenditures & FraudFraud
Projections– Current
14%
– By 2011; 17% ($2.8 trillion)
Examples– Nadolni Billing Service (Memphis)
$5 million in claims to CIGNA for psychological services $250,000 fine (& tax evasion); July 12th
Defining FraudDefining Fraud
Fraud– Intentional– Pattern
Error– Clerical– Dates
Problem: Fraud & Abuse Problem: Fraud & Abuse 26 Different Kinds of Fraud TypesMental Health ProfiledEstimates of Less Than 10% RecoveredPsychotherapy Estimates/Day = 9.67 hoursProblems with Methodology;
– MS level and RN– Limited Sampling
Problem: FraudProblem: FraudOffice of Inspector GeneralOffice of Inspector General
Primary Problems– Medical Necessity (approximately $5 billion)– Documentation
Psychotherapy– Individual– Group
Psychological Testing– # of Hours– Documentation
Problem: Fraud (cont.)Problem: Fraud (cont.)
Nursing Homes– Identification – Overuse of Services
Children Experience
– California; Texas– Corporation Audit– Company Audit– Personal Audit
Problem: Fraud (cont.)Problem: Fraud (cont.)
Estimated Pattern of Fraud Analysis– For-profit Medical Centers– For-profit Medical Clinics– Non-profit Medical Centers– Non-profit Medical Clinics– Nursing Homes– Group Practices– Individual Practices
Problem: Mental vs. PhysicalProblem: Mental vs. Physical
Historical vs. Traditional vs. Recent Diagnostic Trends
Recent Insurance Interpretations of Dxs Limitations of the DSM The Endless Loop of Mental vs. Physical
NOTE: Important to realize that LMRP is almost always more restrictive than national guidelines
Current EffortsCurrent Efforts
Participants– APA Practice– Related Organizations (NAN, SPA)
Activities– E & M Documentation Guidelines– Medical vs. Mental Health Dx– Supervision
Three Levels Physician Supervision is not Required for a Psychologist
– Survey Practice Expense vs. Cognitive Work Professional vs. Technical Component
Possible SolutionsPossible Solutions Better Understanding & Application of CPT More Involvement in Billing Comprehensive Understanding of LMRP More Representation/Involvement with AMA, CMS,
& Local Medical Review Panels Meetings with CMS Survey for Testing Codes APA: Increased Staff & Relationship with CAPP Local Interest Groups and NCPA
Possible Solutions: ResourcesPossible Solutions: Resources
Web Sites– cignamedicare.org– cms.org
- nanonline.org– div40.org– clinicalneuropsychology.com
Publications– Testing Times: Camara, Puente, & Nathan (2000)– General CPT: NAN & Div 40 Newsletters
Future PerspectivesFuture Perspectives Income
– Steadier (if economy does not further erode)– Probable incremental declines, up to 10-20%– If Medicaid dependent (25% or more), then declines
could be even higher– “Final” stabilization by 2005
Recognition– Physician Level– Mental vs. Physical Health
Paradigms– Industrial vs. Boutique– Health vs. Non-Health– Primary Care vs. Consulting
Future ProblemsFuture Problems
What Will be Future of Training Programs? Health Care vs. ?
– Who will take care of “mental health” patients?– Will “mental health” & psychotherapy be MS level?– What about prescription privileges?
Boutique Health Care as Income Protection?– e.g., $1,500 to $20,000/year for a patient which would include;
round the clock availability e-mail, fax to physicians prompt appointments special services (e.g., wellness)
Future PerspectivesFuture Perspectives
New Paradigm = Change
Case ExamplesCase Examples
IntakeTherapyTesting
Workshop ResourcesWorkshop Resources
Current Procedural TerminologyRVUs & National Payment SchedulesPatient Service FormsCoding SheetBilling FormsCIGNA Local Medical Review PolicyOffice of Inspector General Documents